Junky Elend: Some ways of explaining
it and dealing with it

From a pharmacological explanation
of junky behaviour to a social one

Peter Cohen

This presentation will deal with the question of why heavy
users of opiates and other drugs seem to regularly present themselves
as "junkies". And why the junky 'misery' ('junky elend' as the
Germans say) seems to be different in intensity and effects between countries.
With "junkies" I mean persons of which I will give an ideal
typical definition by means of a complex of characteristics. All of these
may be seen in one case, some in another. It remains a matter of taste
exactly who would qualify. The characteristics usually are: regular use
of opiate type drugs and other licit and illicit substances, dressed in
torn and / or filthy clothes, low standards of personal hygiene, sometimes
hard to understand images of reality, or ways of reasoning. Other ways
in which junkification appears can be low standards of nutrition, no or
very bad housing, socially disgraceful kinds of activities in order to
acquire some money like prostitution or other jobs in the sex industry,
petty theft and robbery of the elderly and (in rare cases) forms of ugly
and aggressive criminality. Of course such junkified drug users are the
most conspicuous ones, a reason why our selective perception easily leads
to the inference all (heavy) opiate users look like that. The term 'junky
misery' refers to the subjectively felt distress of junkified drug users
that may be one of the backgrounds of suicides occurring in this category.

I would like to discuss here some of the ways we might understand the
aetiology of such life styles. How is it that persons can end up like
that, and which role play heroin or other drugs[1].
In short, I am interested in explaining "junkification" of some
drug users.

I have often been confronted with the standard construction of understanding
this phenomenon, which runs somehow as follows: These persons have used
heroin and as we all know, became addicted to this drug very quickly.
In order to satisfy their needs for the drug they first depleted all their
original financial and material resources. After these had disappeared,
they started to steal from their family members and from other people.
They end up frequently in prison and find themselves in an ever down going
spiral until they are junkies. A hardly more sophisticated explanation
one sometimes hears from medical professionals. The basics are about the
same, but medical people will often also see mental pathology in such
persons. It is then the combination of heavy drug use and mental pathology
which causes the social downfall.

To make a long story short, we may summarise the basic construction of
junkification as a consequence of the effects of the substance itself,
a more or less pharmacological explanation. Sometimes this pharmacological
explanation is made more `scientific' by pointing towards studies of rats
or monkeys, where such animals will take a drug until they are either
completely starved or dead. This basic construction does not change much
if it is seen as a consequence of the effects of the substance, coupled
to some psychological process in the user. Psychological process (often
of pathological nature) is assumed to enter in choosing the use
of some drugs or when deciding to continue such use. Theories of self
medication belong in this class.

I prefer to look at the phenomenon of junkification from a different
angle and to leave the pharmacological perspective in order to see if
other explanations of junkification can be made plausible. The inspiration
for this comes from an observation that nowadays is often made: frequency
of junkification in heavy users of heroin or cocaine seems to occur less
and maybe much less in the Netherlands than e.g. in Germany or Switzerland.
In a recent study done among over 200 heavy heroin users in Amsterdam,
Korf found that in general the condition of these people is reasonable
to well.[2]

"Junky Elend" in Germany and Switzerland is often so dramatic
that it fed recent discussions about changes in drug policy in these countries.
In Switzerland, drug misery in the form of very serious and massive junkification
has risen so high to the lips of official policy makers that recently
the Federal Government has proposed, as the only Government I know of,
to start an experimental heroin distribution among addicts. In Germany
the rising number of drug deaths and the dangers of HIV infection seems
to support a less inflexible attitude towards the distribution of methadone.
And in Hamburg a certain loss in rigidity seems to develop towards police
suppression of consumption.

Such moves in drug policy are extremely important as illustrations of
how officials adopt explanations of "Junky Elend". One could
observe that in both countries changes in drug policy are directed towards
giving junkies the drugs (or the replacements thereof) these people seem
to want. At the same time one recognises in such changes where officials
feel the main cause of the problem is located: in the (scarcity of the)
drug. Once the drug could be made more available on a regular basis supervised
by responsible people, one could perhaps expect a lowering of "Junky
Elend".

Because the drug problem as constructed by many policy makers is located
in the drug of use, one could say that the core construction of the drug
problem and the core constructions about how to deal with it are pharmacological.
This runs parallel to what we just saw as the standard explanation of
junkification. At the same time for many people such changes in drug policy
are not understandable, and many feel morally opposed. There seems to
be a flaw in the argumentation, according to opponents of drug distribution
policies. They will say that the basic reasoning behind giving people
the drugs they need is that they will be able to leave the type of life
they were forced into because of using the drug. So it is crazy to give
it to them. I remember very vividly the triumphant exclamations of medical
people opposing heroin distribution in Amsterdam that "nobody would
give alcohol to alcoholics to help them". This apex of analytical
reasoning and non comprehension of junky elend was very often enough to
give policy makers in favour of heroin distribution a facial expression
of utter despair and helplessness. Understandably so. Once one accepts,
implicitly or explicitly that the cause of junky behaviour is located
in the very substance consumed (with or without the complication of mental
pathology), giving junkified users this substance seems immoral and indefensible.
Sometimes one will hear that at least the advantage of heroin or methadone
distribution is that people will no longer have to prostitute themselves,
or steal and rob to get their stuff. But the puritans of drug assistance
will retort that this is a selfish argument only designed to relieve the
citizens of some criminality. It has nothing to do with helping the addict,
let alone curing him. One understands that the construction of why people
"junkify" is very important for the creation of assistance strategies.

In a psychological construction of illicit drug use and / or junkification
one will see the "cure" in a complete psychological restructuring
of the drug user. His personality will have to disappear and be exchanged
for a non drug using personality. In such a problem construction junky
elend is a positive force because it will confront the junky with so much
stress and misery he will ultimately accept the psychological treatment
designed for him. This problem construction is quite distasteful to me.
Behind it some of the most brutal so called treatments find their legitimization.
It makes mockery of the sometimes valid observation that for some proportion
of heavy drug users, drug consumption and some sort of neurotic or even
psychotic problem may influence each other. In stead of a careful analysis
and individualised assistance of each individual case (as is common in
all other branches of medicine and social work), we sometimes see junky
restructuring plants in the guise of drug free communities where a good
for all general treatment is offered.

A social and social psychological construction of junky elend

As an introduction to a different construction of the problem
of junkification I would now like to look for a moment at modern sociological
theory of poverty. In many western industrialised countries open evidence
of poverty is becoming a problem. In spite of all kinds of measures to
help the poor, it seems that poverty is not at a decline, on the contrary.
Most of us who have visited the United States know that leaving the boundaries
of the `good' parts of cities changes the urban scenery dramatically.
And sometimes even the better parts are now disturbed by the poor who
live in subway stations, shopping malls and parks. In most European cities
poverty is less abundant but not absent. The importance of the theme is
so large that it has grown into a specific field of scientific inquiry.

Modern reflections about poverty can be made to use in the discussions
about Junky Elend. According to an overview of poverty literature and
on the basis of his own empirical investigations, Engbersen defines a
few essential characteristics of modern poverty.

Poverty means insufficient resources to survive. Here not only material
but also social ones are included like means for communication, means
for upholding relevant social ties and means to be able to use basic
institutional resources like education.

Poverty is being ostracised from main stream society.

Poverty is polyform deprivation. Here one should understand a cumulation
of insufficiencies. People have debts, no employment, no inspiring perspectives
on changes of the situation, no education, health problems, no supporting
social networks. "Those who score low on these dimensions find
themselves in a situation of poverty"[3]
(Engbersen 1991, page 11), resulting in a structural inability to overcome
such poverty.

One of the most depressing characteristics of modern poverty seems to
be the dependence on state governed institutions. Whatever means poor
people can mobilise is often mediated by state institutions. At least
in the Netherlands this is the case. And because state institutions have
to get by ever decreasing resources, there is a lot of pressure from these
institutions on lowering their participation in the lives of the poor
they take care of. One should add constant stress as a variable in the
lives of the poor. Dealing with continuous deprivation in many areas of
life is stress inducing, in itself a very destructive force in the lives
of the under-privileged.

Now let us go back to our topic, the existence of junky elend and its
explanation. Junky lives are characterised by many or all of the essential
requisites of the lives of the poor or otherwise underprivileged. On some
characteristics they might score even higher than "normal" poor.
Certainly on the variable of social ostracism they will score extra high
in most countries. The same can be said of absence of supporting social
networks, and the lack of future prospects. In terms of state dependence
they show a very high level of contact with police, medical institutions
and other suppression agencies. These agencies often make or break the
day of a junky. So, one could consider the life of some proportion of
heavy drug users (so called junkies) as characterised by an even higher
level of polyform deprivation as is the case with other poor. Ergo, their
social situation is even more filled with daily problems as other underprivileged
in society. As we saw, one of the essential characteristics of poverty
is the inability to overcome the self perpetuating state of being poor
once below a certain level.

One of the assumptions of this essay is that levels junkifications and
its resulting junky elend in different countries are not the same and
that the level in the Netherlands seems to be lower than in countries
nearby. The problem we have to solve now is how this could be explained.
The easiest solution of this problem is saying that since nobody ever
measured levels of junky elend per country with objective instruments,
the problem can not be discussed in a satisfactory way. Scientifically
there is no ground to state that e.g. Germany of Switzerland have higher
levels of junky elend than Holland. I tend to agree with such statements.
Of course there is the conspicuous fact that drug related deaths in the
Netherlands decline, while in Germany and Switzerland the number is rising.
But this could be an artefact of different measuring criteria of drug
deaths, and the some times fuzzy or changing diagnostic base of drug related
death in general. Still, apart from the data we have from research among
Amsterdam junkies I have been so often confronted with observations from
different drug workers and experts who simply state from their experience
that junky elend in the Netherlands is less than elsewhere. Such observations
come both from Dutch and foreign observers. This primitive condition of
our comparative knowledge about the level of junky elend in different
European countries will only disappear if we decide to do comparative
research on this issue. Until such research is done, we either consider
speaking of "levels of junkification" as improper, or we take
as point of departure a not properly scientific set observations still
open for verification. For the time being, I prefer to assume that junky
elend is less in Holland than in Germany or Switzerland in order to work
on designing a way of looking at this problem that in the end might allow
for a more empirically tested explanation. This means one would have to
decide on variables one would have to measure if one would want to empirically
verify the assumption and its explanation.

Let us start with investigation of some variables related to the drug
itself, in this case heroin.[4]
To begin with amount of heroin consumed, one can observe that prices of
heroin and its quality are very different between the mentioned countries.
In Amsterdam the price of about 20-40% pure powder heroin is around Hlf
100 per gram. In Hamburg heroin is about three times as expensive and
in Zürich about six times for less pure substance on the local black
markets. This means that if one is fully participating in the junky life
style, very probably the amount of active substance consumed by junkies
in Germany or Switzerland is probably not more than the amounts consumed
in Holland. It might even be less (ref. here to Leuw and Korf data). More
over, methadone is easily available for the Dutch junkies, also in the
streets in the so called grey methadone market. So, the level of opiate
consumption on average might be higher in Holland than in the other two
countries. Still, we work with the assumption Dutch junkies are far less
"verelendet" than elsewhere. The substance itself can not explain
this difference. Because, if the substance itself would lead to junky
elend, we might see the same levels of junkification in the Netherlands
as elsewhere. And we have seen some plausibility of an assumption that
because if lower price, higher purity and easy availability of methadone
levels of opiate consumption among ' junkies' in Holland might even be
higher. This would make us expect higher levels of junkification in the
Netherlands if opiates themselves would cause junkified behaviour.

Maybe the proportion of injecting users and the social conditions around
injection explains some of the difference. We know that in Amsterdam about
28% injects and the rest smokes heroin the Chinese way (Korf et al 1990).
In the rest of the Netherlands, the proportion of non injecting heavy
users is at least equal, if not higher[5].
More over, sterile injection equipment is abundantly available. This means
the risks of injecting do occur necessarily less in the Netherlands than
in Germany or Switzerland where a much higher proportion is injecting
and where only limited supply of clean injection equipment is realised.
Risks of non sterile injections like endocarditis, abscesses, hepatitis
and HIV are serious and will affect some users to such a degree that spectacular
physical and mental downgrading develops. In a country where social conditions
around intravenous drug use are very unfavourable, like in Germany and
Switzerland, and where very high proportions of heavy users do inject,
injecting may explain a certain amount of the difference in junky elend
between the countries we are looking at.

We might now shift our perspective and look at some social aspects of
junky elend. To begin with, unfavourable conditions for a sceptic injecting
are not objective facts of material nature, but socially constructed states.
This means that theoretically in a socially well organised situation i.v.
drug users might never have to practice primitive or non sterile injection.
Intra muscular injection, although less difficult than i.v. injection,
causes almost no problems with self injecting diabetes patients. Also,
low prices of heroin and wide availability make it very easy for heavy
heroin users not to inject. This is also a result of a certain policy,
I will discuss a little later.

But, there is another kind of social aspects of junkification, which
is grounded in a special kind of general social interaction between 'normal'
members of society and junkies. I still support Zinberg's view that junkification
might be understood as a normal consequence of stimulus deprivation (Zinberg
and others[6] ref. to Cohen
1984, in Cohen 1990). By forcing heavy users of heroin in severely ostracised
and a-social situations, their ways of relating to the social world around
them will change. One of the consequences of ostracism is that many users
are no longer seen as normal persons towards whom normal behaviour is
required. In their turn heavy users will experience that if they behave
normally this has little effect on the way they are treated. Their behaviour
is met with enormous distrust. Ergo, users will say good bye to the old
rules of behaviour because these rules are not productive for them. Abiding
or not abiding to basic social rules will make little difference on their
being seen as outcasts. So why stick to the rules. On the other hand,
living the life of an outcast and paria is extremely difficult and many
are in danger to collapse psychologically in the process. Very special
kinds of adaptation to this are required, adaptations that will in turn
enhance or at least confirm the outsiders view of the 'crazy junky'.

For a drug user in general one of the most wounding experiences is that
something of very high subjective value, the drug induced state of consciousness,
is totally unacceptable for others. Or, in other words, a central part
of ones identity is socially unacceptable. For some heavy and regular
users this means saying good-bye to the drug, for most it means saying
good-bye to their old social world and its criteria for socially acceptable
behaviour. This process occurs every where and is not restricted to specific
countries. Contrary to what one often hears is that also in the Netherlands
the attitude of the public towards heroin and junkified drug users is
extremely negative. The social risks of regular heroin use therefor are
high. Very high. And in my opinion of foremost importance, well above
any pharmacological risks. But there are considerable differences, both
in the ways these social risks present themselves as in their severity.
Although ostracism will occur in all western countries where heavy use
of illegal drugs occur, society can organise ways by which to at least
partly neutralise these effects. I will come back to this notion of compensation.

I will now discuss, in arbitrary order, some other elements that may
explain the assumed differences in junky elend between The Netherlands
on the one side and Germany and Switzerland on the other. The existence
and accessibility of assistance options is one of them.

The drug economy

Drugs are relatively cheap in the Netherlands. Not only
the socially more accepted drugs like tobacco, alcohol and cannabis, but
also heroin and cocaine. Price of heroin is as I already mentioned one
third to one fifth of heroin in the two other countries. Also, the purity
of heroin, mostly the light brown powder variety, is decent and according
to as yet unsystematic sources, quite regular.[7]
Most users will be able to buy a quarter gram in the street market for
around Dfl 25.-. One hour in the disco is more expensive. On top of this,
when a user does not have Dfl 25.- to buy a small dose, he will be able
to find methadone in the street markets. For 5 mg of methadone a user
will pay about Dfl 2.50. This means a mere Dfl 10.- will buy him a dose
of methadone sufficient to deal with abstinence symptoms. As you may understand,
this state of affairs will take some pressure and stress out of junky
existence.

The personal survival economy

In the large user study Korf published about Amsterdam
in 1990 we find that 85% of his population has a basic economic assistance
from one of the social schemes in operation in the Netherlands. For 39%
this form of assistance is also the main income and for 44% an important
source. Other sources of income are sex business and drug sales to others,
but these are less secure and regular. Almost one in ten has a regular
job and about 13% has strictly illegal sources as main income.

In their personal economy there is ample room for choice. Not only Grapendaal
(1989) but also Korf (1990) found that the heavy drug users in Amsterdam
will on average first cover their basic survival costs and only after
this spend the rest on drugs. Average drugs spending per week is Dfl 575.-
and median drug spending is Dfl 350.-. Roughly one third of these sums
is spent (average / median) on basic survival costs like housing food,
electricity and heating.

For those users who find repeatedly they are not able to manage their
personal survival economy a service has been made available which is called
"basic income management". If a client wishes, all his legal
income is managed by an institution who takes care that basic survival
costs are paid. The rest is paid in daily instalments to the client. This
service is very popular with a certain kind of heavy drug user (see Schagen
forthcoming, 1991). The availability of housing for heavy heroin users
is of course very important. Many of them, even of the so called "
Extra Problematic Users" investigated by Derks (1990), keep their
houses in a well cared for and decent state. See Korf et al's study of
drug users in a rural area for similar observations (Korf et al 1989).[8]
This means that for a lot of regular opiate users in Amsterdam conditions
prevail that keep a minimal social integration in tact. We may expect
this is not different in other cities in the Netherlands. Without any
certainty we may assume that the upkeep of these social conditions will
counteract junkification. In as far as social services that support social
integration are easier available in the Netherlands than elsewhere, this
might help explain differences in levels of junkification.

Neutralising the effects of social ostracism

In the Netherlands, heavy drug users are socially not accepted.
A simple visit to an Amsterdam or Rotterdam metro train will make this
clear to any foreigner. At the same time, Dutch society uses one of its
characteristics to neutralise the effects of this in a certain minimum
way. This characteristic is that the Dutch socio economic system has generated
over the last forty years an immense variety of care and assistance institutions
for a large number of groups, sub groups and sub groups of sub groups.
Just to exaggerate a bit, I would not be surprised if the Foundation for
Blind, Left Handed Photographers would have a special branch for supporting
those members who have difficulty living in streets where the tramway
passes. Somehow there will be a medical and social support system for
almost any sub group, of course heavily financed by the Hague or a private
source. Very many groups, especially those who are socially or economically
weak, will find some sort of institution that will either take care, or
organise such care. In the case of heavy heroin users the last ten years
have given birth to a large variety of state financed care institutions
that are an essential part of understanding levels of junky elend in the
Netherlands.

One of the most important care systems is of course the economic one
operating for all poor, which is used by a majority of heavy drug users.
Second, all big and smaller cities have branches of the local Health Departments
specially set up for heavy drug users. Such Institutions will take care
of methadone distribution, health care and medical crisis intervention
when needed. In many of these health care institutions some representative
of the social assistance system has a place, which means that heavy users
receive help finding a house, solving problems with their landlords, solving
problems with their children, solving problems with the Electricity Company
when bills are not paid, etc. I do not say that such assistance is often
needed, or that these institutions are always efficient, or that personnel
working in such offices are always nice to their clientele. But they are
available, and really used. And in the bigger cities, methadone maintenance
has been diversified into many different forms. So has health care. Some
half of all methadone in Amsterdam is distributed through the normal and
regular channel of the general practitioner. The other half is divided
between a no strings attached methadone bus, slightly more controlling
systems and severe, urine controlled systems working towards total abstinence
that throw a client out if he/she violates the rules. For many different
methadone needs and regimes there is a solution. All of these systems
are quite accessible[9].

This relatively high level of diversification not only of methadone maintenance
but also of economic and other services is one of the most essential factors
explaining elements of a lower level of junky elend in the Netherlands
than in Germany or Switzerland. Note I do not say junky elend is absent.
But there is some form of help available if needed, which means a strong
mitigation of the impact of social risks of heavy drug use. The most terrible
of risks for a human being, not to be treated as one, is utterly destructive
in its effects. Such destructive effects are part of the misery known
as Junky Elend for Junkies. If institutions have to replace a good part
of normal inter personal communication and compassion this is bad, but
the absence of such institutions is worse.

The police

In Bossongs and Stöver's study "Methadon"
(1989) a German junky says about some moment in his life: "Ich war
am Ende, meine Familie war zerbrochen, die Freunde fort. Für mich
begann damals der Teufelskreis Sucht-Verfolgung-Inhaftierung"[10]
Also in the Netherlands about 25% of prison inmates are in prison for
criminality which is supposed to be drug related. But none of these people
is there because of consumption, and very few because of small dealing.
The policy of arresting heavy drug users because they were caught injecting
or smoking drugs or buying some small quantity of drugs has been left
behind. Even small scale dealing from apartments is not interfered with
if neighbours do not complain. One could say that in daily practice consumption
and sales for consumption are no longer objects of police interference.
Quite a lot of pressure is taken away from heavy drug users this way,
which explains still another part of the lesser level of junky elend in
the Netherlands.

Final comments

I have presented to you some possible explanations of the
assumed lesser level of junky elend in the Netherlands than in Germany
or Switzerland. In doing so I switched perspective from a basically pharmacological
explanation of junky elend to a social one. The core of junky elend is
the same as the misery for other much larger groups of underprivileged
persons in our industrialised cultures. Only, these factors are amplified
X times for heavy users of drugs, certainly opiates.

Dealing with junky elend from a pharmacological view on the problem will
not suffice, not even nearly. Although drugs and their economy have some
impact on the level of junky elend, I do not see this as directly active
factors but as indirect factors. Drugs and drug economy affect junky elend
via the level of social risks junkies are confronted with. The social
risk that causes a lot of junky elend is ostracism, or no longer being
treated as a human being by large segments of significant others and institutions
in society. Social and psychological support systems break down for poor
people, and much more so for ostracised drug users.

The most promising strategies of lowering levels of junky elend among
which junky dying, is to interfere in the process of social ostracism
by creating neutralising institutions. These institutions have to work
on the level of the daily problems of heavy drug users and not on the
level of monolithic pharmacological or psychological constructions of
their problems. Once the daily problems of junkies are taken as point
of departure for an assistance policy, one will find quickly enough where
particular problems have a pharmacological or psychological side to them.

It would be extremely interesting to find out if different levels of
junkification can be measured, and if lower levels of junkification are
associated to social conditions that put junky life styles under less
social pressure. Also, it would be necessary to find out if the existence
of social assistance systems that to a certain degree compensate for social
ostracism, prolong junky careers as suggested by Leuw. Or, on the other
hand, shorten them because the social forces that keep junkies out of
conventional social structure remain so strong that little other choice
is left.

Heroin and methadone distribution will probably have less effect on junky
elend than would be possible, if

they are not coupled to an acceptance of heavy drug use as a legitimate
life style,

not available through a differentiated set of regimes of distribution
according to the needs of the users, and

not coupled to a series of social work activities that are designed
to compensate the destructive effects of not being accepted in the conventional
social structure of normality.

Notes

I will not discuss questions of why people use
heroin in one pattern or another, why some get "addicted"
and others not.

This means e.g. that 88% has reasonable housing,
that about one third of friends and acquaintances are non drug users,
that when in need for them 95% has been in contact with one of the drug
assistence institutions and that the average psychological condition
is worse than the level 'normal dutch citizen' and better than the level
of the ambulant psychiatric patient. See for an abundance of data Korf,D.
en Hoogenhout, H.: "Zoden aan de dijk. Heroinegebruikers en hun
ervaringen met en hun waardering van de Amsterdamse drugshulpverlening"
Universiteit van Amsterdam 1990.

In reality no heavy user of heroin uses heroin
only. Many will also use alcohol, tobacco, pharmaceutical drugs and
cocaine in diferent degrees. But this true in all three countries under
discussion here.

At the moment Korf is doing a price-purity study
in Amsterdam, purchasing samples of five illicit drugs several times
a month in different sectors of the market. These samples are analysed
on quality and weight by the local Police Narcotics Laboratory. This
study will yield the first systematic data of its kind in the Netherlands,
and possibly in Europe.

One should not underestimate the importance of
low threshold programs. Such programs are characterised by many aspects,
but maybe the most important one from a subjective point of view of
the client is that he is accepted as a heavy drug user. He does not
have to hide he is one. Because he is one he is accepted in such
institutions. And because the use of heroin next to methadone is not
a reason to throw a client out, methadone distribution is for a certain
class of clienst one of the few certainties they enjoy.

This is perceived as a kind of social recognition
which prevents a subjectivity of a total outcast, a total paria. I do
not know how true this is, but according to several observers the inter
junky level of agression is much lower in Dutch cities than in Hamburg
or e.g. New York. People will easily share drugs with each other and
be friendly. In as far as this is true this may stem from the availability
of parts of the social system that accept the drug user identity. Some
external acceptance will save some internal acceptance, resulting into
less interpersonal agression.